Contributors: Brendan Corcoran, Yolanda Martinez Pereira

 Species: Feline   |   Classification: Miscellaneous

Introduction

  • Patients with respiratory disease can present with a variety of clinical complaints such as coughing (most common), sneezing Sneezing, other upper airway noises often referred to as reverse sneezing, nasal/ocular discharge Rhinitis, decreased exercise tolerance, abnormal respiratory noise (stridor and stertor), abnormal breathing pattern, breathlessness, increased panting, collapse, acute respiratory distress Acute Respiratory Distress Syndrome (ARDS), dyspnea, cyanosis.
  • Coughing is the most common complaint and can be classified as acute or chronic:
  • Dyspnea is also a common complaint and can be further classified as inspiratory or expiratory:
    • Inspiratory dyspnea indicates a problem of the upper airways: nasal disease, brachycephalic obstructive upper airway syndrome (BUAOS), nasopharyngeal polyps Nasopharyngeal polyp, tracheal collapse, foreign body, neoplasia (rare).
    • Expiratory obstructive dyspnea indicates a problem of the lower airways that leads to obstruction of the normal airflow: lower airway foreign body, neoplasia, feline asthma (bronchoconstriction), bronchitis, extraluminal airway compression (such as neoplasia or fibrosis).
    • Expiratory restrictive dyspnea (shallow, short breathing) indicates a problem of the lower airways that leads to abnormal ventilation and/or perfusion: pleural effusion Pleural effusion, pneumothorax Pneumothorax, diaphragmatic hernia Diaphragm: hernia, pulmonary edema Lung: pulmonary edema, pneumonia, interstitial pulmonary fibrosis, neoplasia, pulmonary hemorrhage/contusion Lung: pulmonary hemorrhage. Includes abdominal conditions that exert pressure over the diaphragm, such as abdominal effusion Peritoneal: effusion, organomegaly Abdominal organomegaly, pregnancy, etc.
  • Abnormal respiratory noises can help in identification of the abnormal anatomical area:
    • Inspiratory stertor usually indicates a nasal problem.
    • Inspiratory stridor is usually associated with problems in the larynx (eg laryngeal paralysis).
    • Reverse sneezing is usually associated with problems in the nasopharynx (eg foreign body).
  • Nasal discharge can be bilateral or unilateral, and the discharge can be serous, hemorrhagic, mucoid, purulent:
    • Unilateral nasal discharge can be associated with foreign body, neoplasia, nasal aspergillosis Aspergillosis.
    • Bilateral nasal discharge is more likely associated with lymphocytic-plasmacytic rhinitis (LPR), aspergillosis, neoplasia Nasal cavity: neoplasia.
  • Cyanosis is characterized by a bluish color on the mucous membranes and is due to a low percentage of saturation of hemoglobin with oxygen (which is an increased amount of the reduced form of hemoglobin) or to the presence of metahemoglobin. In anemic patients, cyanosis may not appear obvious due to the decrease amount of hemoglobin in blood. Cyanosis can be central or peripheral and may be intermittent or persistent. A patient with cyanosis represents a true respiratory emergency.
  • Some respiratory diseases have been described more commonly in some breeds, such as:
  • BUAOS affects brachycephalic breeds (eg Persian cats Persian longhair).
    Follow the diagnostic trees for Dyspnea Dyspnea, Panting Panting, Respiratory distress Respiratory distress, and Abnormal Respiratory Sounds Abnormal respiratory sounds.

History taking

Identification of the primary problem

  • The history, combined with the information obtained from the physical examination should help the clinician to indentify the primary problem/s, so a differential diagnosis list and a protocol for investigation can be formulated. Attention must be paid to rule out a cardiovascular explanation for the clinical presentation.

Background history

  • The age of the patient should be recorded, as infectious respiratory diseases are more likely in young patients, whereas neoplastic conditions will be more likely in older or geriatric patients.
  • If multi-pet households, the clinician should enquire if any respiratory clinical signs have been noted in other pets (eg kennel cough is highly contagious).
  • The vaccination and worming state should be recorded, with special attention to ascertain if the worming product used is active against the lungworm parasites. Preventative treatment for dirofilariosis Feline cardiopulmonary dirofilariasis in endemic areas and travel history should be enquired.
  • It is important to obtain information about the environment:
    • Vegetal foreign bodies may be more common in rural environments.
    • Feline asthma may be worsened by cigarette smoke exposure. Also in cats with clinical signs compatible with asthma, perfumed litter or covered litter trays may contribute to worsening of clinical signs.
    • Exposure to inhaled irritants (eg house refurbishing) might lead to airway inflammation.
    • Foxes in the locality and contact with slugs, etc may predispose to lungworm infection Aelurostrongylus disease.
  • History of previous diseases and/or traumas should be collected (eg patients with history of mammary gland tumor Mammary gland: neoplasia removal may show metastatic lung disease at a later stage), even if several years have passed.
  • Collection of information regarding current medication, as well as clinical response to previous treatments (eg chronic coughing over years that improves with steroid treatment is more likely to be due to underlying respiratory disease than cardiac disease).
  • It is important to obtain information regarding the level of activity of the patient, as it will help interpreting the severity of clinical signs such as decreased exercise tolerance.

History for specific complaints

Coughing

  • Coughing is one of the most common complaints in patients with respiratory disease, but also in canine patients with cardiac disease.NOT common in feline patients with cardiac disease.
  • In patients with respiratory disease, the coughing may be triggered by presence of mucus in the airways, by physical compression or mucosal inflammation.
  • Additional history to be taken in patients with coughing:
    • Is it productive, non-productive?
    • What's the frequency? - eg daily, nocturnal, etc.
    • What's the progression (acute coughing versus chronic coughing)?
    • Any triggers?
    • The clinician should try to differentiate coughing from other clinical signs such as gagging, retching, reverse sneezing, sneezing - the difference may not be obvious to the pet owner.

Abnormal respiratory noises

  • The clinician should try to obtain a description of the noise (owners can be encouraged to obtain a video of the abnormal noise):
    • Upper airway respiratory noise: occurs during inspiration:
      • Nasal stertor - may be accompanied with sneezing, nasal discharge.
      • Laryngeal stridor - may be accompanied with changes in barking or coughing triggered by eating or drinking in patients with laryngeal paralysis.
      • Snoring - common in patients with elongated soft palate.
      • Lower respiratory noise:
        • Wheezes: inspiratory and expiratory.
        • Ronchi: inspiratory and expiratory.
        • Crackles: inspiratory only.

Physical examination

General examination

  • Patient demeanor and responsiveness, eg bright, alert and responsive.
  • Body condition score - a scale out of 9 can be used Body condition scores.
  • Assessment of the resting respiratory rate and the breathing pattern: inspiratory dyspnea, expiratory dyspnea, restrictive breathing pattern, paradoxical breathing pattern.
  • Lymph node palpation and neck palpation in old cats (thyroid gland).
  • Assessment of mucous membranes: color (pink, pale, cyanotic, congested), moisture (dry, tacky, moist), CRT, presence of halitosis.
  • Assessment of pulses (femoral, peripheral): presence of pulse deficits, pulse quality.
  • Chest palpation: the apex beat is usually displaced caudally in patients with cardiomegaly, or muffled or displaced in patients with intrathoracic fluid or masses. In patients with loud murmurs (grade 5 and 6/6) a thrill is palpable over the point of maximum intensity of the murmur Cardiac sounds: overview.
  • Chest percussion: a fluid line might be noted in patients with pleural effusion. In pneumothorax thoracic resonance is increased, whereas it will be decreased in presence of lung consolidation or effusion.
  • Chest auscultation: should include cardiac and lung auscultation (see next)
  • Fluid thrill and hepatojugular reflux.
  • Abdominal palpation.

Respiratory examination and thoracic auscultation

  • In animals with nasal discharge:
    • Check nasal airflow patency with a piece of cotton wool or a chilled glass slide.
    • Check for facial asymmetries or facial pain on palpation.
    • Check ocular retropulsion.
  • The larynx and trachea should be palpated carefully - patients with respiratory disease are prone to cough on tracheal palpation. Dorso-ventral flattening of the trachea might be appreciated on palpation.
  • Respiratory auscultation:
    • Laryngeal and tracheal auscultation should be performed to help localizing upper respiratory tract noise (eg laryngeal stridor in laryngeal paralysis):
      • In brachycephalic breeds it is common to hear referred upper respiratory noise during lung auscultation.
    • Lung auscultation should cover the 4 quadrants of the chest (dorsally, ventrally, right and left).
    • Normal breath sounds (also known as bronchovesicular sounds) should be present - and can be absent with pleural effusion Pleural effusion, pneumothorax Pneumothorax, presence of mass or lung consolidation.
    • Adventitious sounds (abnormal) should not be present - if they are present they suggest underlying pathology:
      • Wheezes - air passing through narrowed airways (eg asthma).
      • Crackles - fine crackles can be heard in patients with severe pulmonary edema during inspiration; coarse crackles can be heard in patients with parenchymal lung disease such as interstitial fibrosis.
      • Rhonchi - can be found in patients with airway obstruction or where there is increased ventilatory demand requiring motre rapid and/or deeper breaths; they can be heard for example with presence of mucus in distal airways in patients with chronic bronchitis).
  • Cardiac auscultation:
    • Assessment of the audibility of the heart beat - muffled heart sounds can be found in patients with pericardial or pleural effusions, obesity Obesity, pneumothorax, pneumonia, intrathoracic masses Thorax: masses.
    • The heart rate and rhythm should be assessed and recorded. Normal rate and rhythm would suggest the presenting complaint is not due to cardiac disease:
      • Regular rhythm; with normal rate (sinus rhythm).
      • Sinus arrhythmia; so called irregularly irregular rhythm that might vary with phases of breathing (faster during inspiration, slower during expiration) with a normal rate.
      • Regular rhythm with bradycardia; sinus bradycardia or third degree heart block.
      • Irregular rhythm with tachycardia; atrial fibrillation or ventricular dysrhythmia/tachycardia
    • The presence of murmurs should be noted, described and recorded, but their presence does not imply a cardiac cause for the clinical presentation Heart: disease - clinical investigation.
    • Intensity of the murmur:
      • Grade I - only heard in very quiet environment in a calmed patient, difficult to hear.
      • Grade II - very quiet murmur but can be heard clearly when in the right position.
      • Grade III - easy to hear but not louder than the cardiac sounds (S1, S2 or loop-doop).
      • Grade IV - easy to hear, louder than the cardiac sounds.
      • Grade V - loud murmur, a thrill can be palpated.
      • Grade VI - loud murmur, a thrill can be palpated and the murmur can be heard when the stethoscope is not touching the chest wall.
    • Timing:
      • Systolic - the most common murmur in small animals, caused by mitral/tricuspid valvular regurgitation and aortic/pulmonic stenosis.
      • Diastolic - less common murmur, found associated to aortic insufficiency or mitral/tricuspid stenosis. Can be a sign of endocarditis.
      • Continuous - found in conditions such as congenital patent ductus arteriosus.
      • To-and-fro - less common murmur, usually caused by complex congenital heart disease.
    • Character:
      • Harsh or ejection murmur; typically due to a stenotic lesion.
      • Soft or regurgitant murmur.
    • Point of maximum intensity:
      • Left base.
      • Left apex.
      • Right side.
    • Presence of other abnormal heart sounds should be assessed such as:
      • Split S2 - found in patients with pulmonary hypertension (eg secondary to respiratory disease - cor pulmonale).
      • Gallop sound - relatively common in feline patients with cardiomyopathy Heart: hypertrophic cardiomyopathy.
      • Other parts of the physical examination are important in patients presenting with decreased exercise tolerance, as for example:
    • Ocular examination Eye: examination: to detect signs of systemic hypertension Hypertension, such as retinal vascular tortuosity or detachment, especially in geriatric feline patients.
    • Orthopedic examination.
    • Neurological examination Neurological examination.

Diagnostic tests